Introduction

Chronic abdominal pain (CAP) occurs in up to 50% of patients with Inflammatory Bowel Disease (IBD), even in remission¹. Previous studies demonstrate that CAP is associated with fatigue, depression and reduced quality of life in IBD patients². These studies, however, are mostly retrospective questionnaire based which are subject to recall bias.
The Experience Sampling Method (ESM) is a digital patient reported outcome measure (PROM) allowing real-time assessment of current symptoms and reduces recall bias compared to end of day or end of week surveys^3,4. ESM has not been used in IBD patients to evaluate the relationship between pain, psychological profile and autonomic symptoms.

Aims & Methods

69 patients with newly diagnosed IBD within the last 12 months were included in the analysis. Patients completed an ESM-based PROM (with a maximum of 10 buzz questionnaires per day) for 7 consecutive days. Within each of the ESM questionnaires, patients reported on current abdominal pain, anxiety, mood, and autonomic symptoms on a scale from 0 (not at all) to 10 (very much). The mean score across the 7 days was calculated for each of the symptoms. Only patients who had completed >25% of the ESM questionnaires (18/70) were included in the analysis.

Results

63 patients completed >25% of the ESM questionnaires (age range 18-62, 34 male, 29 female) and were included in the analysis. 39 patients (62%) had no abdominal pain (mean pain score 0-1), 15 patients (24%) had mild pain (mean pain score 1-4), whilst 9 patients (14%) had moderate/severe pain (mean pain score 4-10).
The mean scores for low mood (2.35, 95% CI 1.69-3.00) and anxiety (1.57, 95% CI 0.78-2.37) were higher in the mild pain group compared to the mean scores for low mood (1.25, 95% CI 0.75-1.76) and anxiety (1.01, 95% CI 0.59-1.43) in the no pain group (p < 0.01). Likewise, the mean scores for low mood (4.59, 95% CI 2.93-6.25) and anxiety (3.59, 95% CI 1.64-5.53) were higher in the moderate/severe pain group compared to the mild pain group (p < 0.05)
There was a higher mean score for palpitations and dizziness in both the mild pain and moderate/severe pain groups compared to the no pain group (p < 0.01). The mean score for dyspnea was higher in the moderate/severe pain group compared to no pain group (p < 0.05), however it was similar between the mild pain and no pain groups (p = 0.39). Finally, the mean score for sweating was similar between the three groups (p = 0.34).
A strong positive correlation (r = 0.84) between pain intensity and low mood intensity was found (p < 0.01). Similarly, there was also a strong positive correlation (r = 0.82) between pain intensity and anxiety intensity (p < 0.01).

Conclusion

Newly diagnosed IBD patients experiencing moderate to severe abdominal pain are more likely to have lower mood, higher levels of anxiety as well as more symptoms of dysautonomia. Further evaluation of the ESM data will provide a greater insight into the course of symptoms as well as potential triggers for the abdominal pain.
Acknowledgements: Ismaeel Aurangzeb, Iman Khwaja & Ebad Ul Haq are joint first authors.
Reuma Margalit Yehuda & Qasim Aziz are joint senior authors.

References

1: A Rezazadeh Ardabili, et al. DOP07 Chronic Abdominal Pain in IBD Patients in Remission: Real-World Data on Contributing Factors. Journal of Crohn’s and Colitis, 2022. 16(1): p. 56-58.
2: Schirbel, A., et al., Impact of pain on health-related quality of life in patients with inflammatory bowel disease. World journal of gastroenterology, 2010. 16(25): p. 3168-3177.
3: Vork, Lisa, et al. The Experience Sampling Method—Evaluation of Treatment Effect of Escitalopram in IBS with Comorbid Panic Disorder. Neurogastroenterology & Motility, 2019. 31 (1): p. e13515.
4: Klaassen, Tim, et al. Psychometric Evaluation of an Experience Sampling Method-Based Patient-Reported Outcome Measure in Functional Dyspepsia. Neurogastroenterology and Motility, 2021. 33(9): p. e14136.

Introduction

Chronic abdominal pain (CAP) affects 20-50% of patients with Inflammatory Bowel Disease (IBD) despite clinical remission. CAP in the absence of active inflammation suggests altered pain processing and gut-brain axis (GBA) dysregulation. This study explores psychological, physiological and behavioural contributors to inform integrated GBA targeted care.

Aims & Methods

This cross-sectional analysis of 2525 adults with Crohn’s disease (CD) or Ulcerative colitis (UC) recruited from the UK IBD-Bioresource (December 2022-April 2024). 1445 met remission criteria (Harvey-Bradshaw Index <5 for CD, and Simple Clinical Colitis Activity Index ≤2 for UC). CAP was defined using Rome IV criteria as abdominal pain ≥1 day/week for ≥3 months. Pain severity and interference (Brief Pain Inventory) were correlated with psychological (PHQ-15 [somatization], PHQ-9 [depression], GAD-7 [anxiety]), physiological (PROMIS fatigue/PROMIS sleep disturbance), cognitive-behavioural (CBRQ), sensory sensitivity (HSP-SP), personality (BFQ) and resilience (CD-RISC) measures using Spearman’s rank correlation.

Results

Among 1445 patients in remission (mean age: 53±16 years; 48.3% female), 381 (26.4%) met CAP criteria (mean age: 49±14.63 years; 57% female; 61.7% CD;). Pain severity and interference were most strongly associated with somatic symptom burden (r_s=0.47 and r_s=0.52; p<0.0001). Fatigue, depression and sleep disturbance were also significant, alongside maladaptive behaviours including fear-avoidance and resting in response to pain (table 1). Somatic symptom burden explained 27% of the variance in pain interference. Pain severity showed modest associations with age (r_s=0.15, p=0.004) and BMI (r_s=0.15, p=0.006). ). Disease duration was not significantly associated with pain outcomes. Patients with CD reported greater pain interference than those with UC (median =0.432, p=0.016).
Pain interference showed stronger corelations than severity across psychological and behavioural domains, including anxiety (r_s=0.34), symptom focusing (r_s=0.30), neuroticism (r_s=0.28), low sensory threshold (r_s=0.20), and resilience (r_s=–0.24) (all p<0.0001). These interconnected factors reflect shared biopsychosocial mechanisms underlying CAP in IBD during remission.

Table 1. Key Correlates of Chronic Abdominal Pain: Pain severity and Pain interference in IBD Remission

Domain	Pain severity (rs) (95% CI)	p-value*	Pain interference (rs) (95% CI)	p-value*
Somatic symptoms (PHQ-15)	0.47 (0.38-0.55)	<0.0001	0.52 (0.44-0.60)	<0.0001
Depression (PHQ-9)	0.28 (0.18-0.38)	<0.0001	0.48 (0.39-0.55)	<0.0001
Anxiety (GAD-7)	0.12 (0.01-0.22)	0.0255	0.34 (0.24-0.43)	<0.0001
Fatigue (PROMIS)	0.34 (0.22-0.44)	<0.0001	0.49 (0.40-0.57)	<0.0001
Sleep disturbance (PROMIS)	0.27 (0.14-0.39)	<0.0001	0.21 (0.08-0.34)	0.0014
Fear avoidance (CRBQ) Symptom focusing (CRBQ) All-or-nothing behaviour (CRBQ) Resting behaviour (CRBQ)	0.29 (0.19-0.39) 0.15 (0.05-0.25) 0.19 (0.09-0.29) 0.21 (0.10-0.31)	<0.0001 0.004 0.0003 <0.0001	0.30 (0.19-0.39) 0.30 (0.20-0.40) 0.25 (0.15-0.35) 0.28 (0.18-0.38)	<0.0001 <0.0001 <0.0001 <0.0001
Low sensitivity threshold (HSPS-SF)	0.15 (0.04-0.25)	0.2566	0.20 (0.10-0.30)	0.0001
Neuroticism (BFQ)	0.06 (-0.05-0.17)	0.252	0.28 (0.17-0.37)	<0.001
Resilience (CD-RISC)	-0.06 (-0.17-0.05)	0.2566	-0.24 (-0.34- -0.14)	<0.0001

*p-value significance level <0.01
Abbreviations: PHQ-15: Patient Health Questionnaire-15, PHQ-9: Patient Health Questionnaire-9, GAD-7: Generalized Anxiety Disorder Assessment-7, PROMIS: Patient-Reported Outcomes Measurement Information System, PROMIS: Patient-Reported Outcomes Measurement Information System, HSP-SF: Highly Sensitive Person Scale – Short Form, BFQ: Big Five Personality Questionnaire, CD-RISC: Connor-Davidson Resilience Scale.

Conclusion

CAP in IBD during remission involves complex GBA dysregulation encompassing somatic, emotional and behavioural factors. These findings support a biopsychosocial care model and highlight the need for integrated GBA targeted interventions, including cognitive-behavioural therapy and neuromodulation.

Introduction

Abdominal pain is a debilitating symptom in Inflammatory Bowel Disease (IBD). 20–50% of patients experience chronic abdominal pain (CAP), even during clinical remission. Emerging evidence suggests CAP in IBD is influenced by bidirectional gut-brain axis dysfunction, encompassing psychological and physiological factors. Identifying these factors is crucial to advancing targeted interventions and improving patient outcomes.

Aims & Methods

We aimed to delineate psychological and physiological determinants of CAP in patients with Ulcerative Colitis (UC) or Crohn’s disease (CD) in remission. This cross-sectional study recruited 2525 adults through the UK NIHR IBD-BioResource (December 2022–April 2024). CAP was defined as per Rome IV criteria as recurrent abdominal pain ≥1 day/week in the last 3 months. Remission was defined as Harvey-Bradshaw Index <5 for CD, and Simple Clinical Colitis Activity Index ≤2 for UC. All subjects completed validated instruments assessing somatic symptom severity (PHQ‑15), gastrointestinal (GI) symptom burden (GSR), fatigue and sleep disturbance (PROMIS), anxiety (GAD‑7), depression (PHQ‑9), cognitive and behavioural responses to pain (CBRQ), personality traits (BFQ), sensory processing sensitivity (HSP‑SF), resilience (CD‑RISC) and quality of life (EQ‑5D‑5L). Logistic regression analyses identified independent predictors of CAP.

Results

Among 1,445 patients in remission (mean age 53.06±16 years; 48.3% female), 381 (26.4%) reported CAP. Of these 381, mean age was 49±14.63, 235 had CD (61.7%) and 217 were female (57%). Patients with CAP had significantly higher mean scores for somatisation, GI symptoms, anxiety, depression, fatigue, sleep disturbance, quality of life, neuroticism, cognitive-behavioural responses and ease of excitation (all p<0.0001), with lower resilience scores (p<0.001) compared to those without CAP.
Multivariable logistic regression identified independent predictors of CAP; younger age, greater somatic symptom severity, symptom focusing, and residual GI symptoms of indigestion and diarrhoea were significant (table 1). GSRS abdominal pain was excluded as a predictor. The regression model demonstrated strong discriminatory ability (AUC=0.8260) and explained 31.4% of the variance in CAP.

Table 1. Significant Multivariable Predictors of Chronic Abdominal Pain in IBD Remission

Predictor	Odds Ratio (95% CI)	p-value
Age (per year increase)	0.97 (0.95–0.99)	0.0029
PHQ‑15; somatic symptom severity	1.17 (1.09–1.26)	< 0.0001
CRBQ; symptom focusing	1.15 (1.05–1.26)	0.0025
GSRS indigestion	1.65 (1.24–2.21)	0.0006
GSRS diarrhoea	1.37 (1.11–1.69)	0.004

Abbreviations: PHQ-15: Patient Health Questionnaire-15, PHQ-9: Patient Health Questionnaire-9, GAD-7: Generalized Anxiety Disorder Assessment-7, PROMIS: Patient-Reported Outcomes Measurement Information System, PROMIS: Patient-Reported Outcomes Measurement Information System, HSP-SF: Highly Sensitive Person Scale – Short Form, BFQ: Big Five Personality Questionnaire, CD-RISC: Connor-Davidson Resilience Scale.

Conclusion

CAP affects approximately one quarter of IBD patients in clinical remission and is significantly associated with a range of psychological factors. Somatisation, cognitive-behavioural factors including symptom focusing and residual gastrointestinal symptom burden are independent predictors of CAP. These findings highlight the key role of gut–brain axis dysfunction in CAP and support the need for targeted interventions such as cognitive-behavioural therapy or neuromodulation to alleviate pain and improve quality of life in this population.

Introduction

Up to half of inflammatory bowel disease (IBD) patients experience chronic pain despite disease remission. The factors affecting the development of chronic pain are poorly understood and pain-directed therapies are scarce. Our study aimed to compare the clinical features and psychological characteristics of patients with and without chronic abdominal pain (CAP). The current analysis focuses on patients with IBD in remission and used REDCap to capture electronic data [1].

Aims & Methods

This is a cross-sectional online questionnaire-based study of 2381 IBD patients aged 16 years and above. The Rome IV questionnaire was used to diagnose irritable bowel syndrome (IBS). Remission was defined as Harvey Bradford Index (HBI) < 5 for patients with Crohn’s disease (CD) or Simple Colitis Activity Index (SCAI) < 3 for patients with ulcerative colitis (UC) [2]. Participants in remission with at least weekly abdominal pain for at least three months were defined as the cohort with chronic abdominal pain, and the rest were categorised as the pain-free cohort. The independent samples t-test was used to compare mean Body Mass Index (BMI) and age at diagnosis, and the independent samples Mann Whitney U test to compare the non-parametric scale data of the two cohorts. Spearman’s correlation was used to compare the pain intensity and pain interference scores from the Brief Pain Inventory with scale data from the following scales: Big Five Personality Questionnaire (BFPQ), Highly Sensitive Person Scale (HSPS), General Anxiety Disorder-7 (GAD7), Patient Health Questionnaire 9 (PHQ9), and Cognitive and Behavioural Response Questionnaire (CBRQ). Cronbach’s alpha was used to assess the reliability of these scales.

Results

1191 participants in remission were studied. Their ages ranged from 17 to 92, with a mean age of 51, and 52.6% were male. Eighty-eight percent were of White British ethnic origin and 40% were current or previous smokers.
25.9% (308) of those in remission reported CAP, with a mean age of 47 years, and 41.6% of them were males. The mean age at diagnosis of IBD was 35 years in those with CAP in remission, versus 30 in those without CAP (t= -4.548, p <0.001, 95% CI -6.598 to -2.621). In the CAP group, the prevalence of IBS was 73.1% compared to the total prevalence of 18.9% in the remission cohort. The prevalence of CD and UC were 72.4% and 27.6% respectively in the CAP in remission cohort, compared to 61.3% and 38.7% in all remission participants. 34.4% of people with CAP in remission had previous surgery.
There was a significant difference between the CAP and non-CAP cohort median scores with p values < 0.001 for neuroticism from the BFPQ, Ease of Excitation (EoE) from the HSPS, GAD7, PHQ9. The CBRQ components of fear avoidance, embarrassment avoidance, symptom focusing, all-or-nothing behaviour score, and avoidance/resting behaviour score also showed differences between the CAP and non-CAP groups (p <0.001, 95 % confidence interval). Pain intensity and pain interference scores showed positive correlations significant at the 0.01 level with neuroticism, EoE, GAD7, PHQ9, and all components of the CBRQ except catastrophisation score within the CAP in remission group.

Conclusion

Our results demonstrate that an older age at diagnosis, IBS prevalence, Crohn’s disease, neurotic personality type, and certain behavioural and psychological profiles are significant features of IBD patients with chronic abdominal pain in remission. Further studies will help to develop management strategies and to establish causality.

References

1. Farrokhyar, F., et al., Functional gastrointestinal disorders and mood disorders in patients with inactive inflammatory bowel disease: Prevalence and impact on health. Inflammatory Bowel Diseases, 2006. 12(1): p. 38-46.
2. Srinath, A.I., et al., Predictors of abdominal pain in depressed pediatric inflammatory bowel disease patients. Inflamm Bowel Dis, 2014. 20(8): p. 1329-40.
3. Harris, P.A., et al., Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform, 2009. 42(2): p. 377-81.
4. Teruel, C., E. Garrido, and F. Mesonero, Diagnosis and management of functional symptoms in inflammatory bowel disease in remission. World J Gastrointest Pharmacol Ther, 2016. 7(1): p. 78-90.
*Dr Ruqaya Idrees and Dr Pavit Luthra are joint first authors on this abstract.

Introduction

20-50% of patients with inflammatory bowel disease (IBD) experience chronic pain during remission (1-5). The clinical features of IBD patients with and without abdominal pain during remission remain unknown.

Aims & Methods

In a cross-sectional pilot study of IBD patients in remission, our aims were to assess patient recruitment, compliance, feedback to optimise the questionnaires for future use and to determine clinical features that distinguish patients with and without abdominal pain. Online validated questionnaires about disease activity, symptoms and psychological assessment were sent to participants of the UK IBD BioResource (total sample 30,000 patients). Inclusion and exclusion criteria of the IBD BioResource main cohort were applied. Descriptive statistics were used in all participants to assess disease status. Descriptive and inferential statistics were applied to all participants in remission.

Results

​2,050 patients were approached and 291 (14.2%) participated. 249 completed the study and 244 patients were included in the analysis. Technical problems, lack of understanding of the relevance of some questionnaires and their length were identified as factors which affected completion in 35 participants. 244 patients were full responders with 122 (50%) participants in remission, out of which 33 (27%) experienced chronic abdominal pain. Comparison of the remission groups with (N=33) versus without (N=89) chronic abdominal pain yielded higher scores in patients with pain for the following: use of azathioprine (p=0.021); patient health questionnaire 15 score (p<0.001); gastrointestinal symptoms rating scale total score (p<0.001); coping resources inventory health in general ((p=0.046); big five questionnaire neuroticism (p=0.019); highly sensitive person scale- short form total score (p=0.007); cognitive and behaviour responses questionnaire catastrophizing score (p=0.010); Pittsburgh sleep quality index poor sleeper (global score > 5, p=0.03).

TABLE 1. Comparison of patients with inflammatory bowel disease with chronic pain and without chronic pain in remission
Variable	Chronic pain (n=33)	No chronic pain (n=89)	p-value*
Sample	Mean ± SD or N (%)	Mean ± SD or N (%)
Use of azathioprine	12 (36.64%)	15 (16.85%)	0.021
PHQ15 score	8.67 (±3.76)	5.09 (±4.0)	<0.001
GSRS total score	2.06 ±0.48	1.52 ±0.54	<0.001
BFQ neuroticism	4.63 (±0.85)	4.25 (±0.82)	0.019
HSPSF total score	4.00 (±0.81)	3.50 (±0.91)	0.007
CBRQ catastrophizing score	4.64 (±3.63)	2.78 (±2.84)	0.010
*Applied tests were either chi-square, Fisher’s exact, Fisher-Freeman-Halton Exact test, independent t-test or Mann-Whitney U test Abbreviations: IBD= inflammatory bowel disease, SD= standard deviation, N=number, PHQ15= Patient health questionnaire 15, GSRS= Gastrointestinal symptoms rating scale, BFQ= Big five questionnaire, HSPSF= Highly sensitive person scale - short form, CBRQ= Cognitive and behavioural responses questionnaire

Conclusion

Rectifiable factors affecting recruitment and compliance were identified. Differences in symptoms and psychological characteristics exist in patients with IBD in remission with and without chronic abdominal pain. Further research is warranted to translate these preliminary findings into meaningful and personalised holistic treatment options for IBD patients with chronic pain.

References

1. Zeitz J, Ak M, Müller-Mottet S, Scharl S, Biedermann L, Fournier N, et al. Pain in IBD Patients: Very Frequent and Frequently Insufficiently Taken into Account. PLoS One. 2016;11(6):e0156666.
2. Sweeney L, Moss-Morris R, Czuber-Dochan W, Meade L, Chumbley G, Norton C. Systematic review: psychosocial factors associated with pain in inflammatory bowel disease. Aliment Pharmacol Ther. 2018;47(6):715-29.
3. Schirbel A, Reichert A, Roll S, Baumgart DC, Büning C, Wittig B, et al. Impact of pain on health-related quality of life in patients with inflammatory bowel disease. World J Gastroenterol. 2010;16(25):3168-77.
4. Norton C, Czuber-Dochan W, Artom M, Sweeney L, Hart A. Systematic review: interventions for abdominal pain management in inflammatory bowel disease. Aliment Pharmacol Ther. 2017;46(2):115-25.
5. Farrokhyar F, Marshall JK, Easterbrook B, Irvine EJ. Functional gastrointestinal disorders and mood disorders in patients with inactive inflammatory bowel disease: prevalence and impact on health. Inflamm Bowel Dis. 2006;12(1):38-46.

Disclosure

Maike Engelmann-Kewitz: No conflict of interest.
Iman Khwaja: No conflict of interest.
Kazuya Takahashi: No conflict of interest.
Dr. Miles Parkes: No conflict of interest.
Prof. Christine Norton: Consultancy: Pfizer; Lecture fees: Merck, Takeda, Tillotts, Janssen.
Prof. Ailsa Hart: No conflict of interest.
Dr. David Bulmer: No conflict of interest.
Prof. Qasim Aziz: Takeda pharmaceuticals and Classado pharmaceuticals.

Introduction

Surgery represents an important part of the therapeutic armamentarium for the treatment of IBD, and has been associated with variable effects on the psychological profile of patients with inflammatory bowel disease. However, surgical treatment is often distressingly perceived by these patients as the failure of their therapies, and can be a trigger for anguish, anxiety or depression.

Aims & Methods

The aim of this study is to describe the psychological impact of surgery on operated IBD patients.
This is a prospective descriptive monocentric study, conducted at the Department of Hepato-Gastro-Enterology and Proctology "Medicine B" CHU Ibn Sina Rabat, which collected all patients followed for IBD (Crohn's + UC) and who were operated between August 2021 and August 2023, the psychological impact and apprehension regarding surgery will be addressed in this study. Patients of both sexes who agreed to answer the questionnaire were included, and patients who refused to answer the questionnaire and complicated patients who stayed in intensive care were excluded.

Results

43 operated patients were included in our study, including 29 (67.4%) in the emergency setting and 14 (32.6%) scheduled. Mean age was 43 ± 16.17 years. The sex ratio was 1.26 (F/H=24/19). 35 patients (81.4%) were being followed for Crohn's disease and 8 patients (18.6%) for ulcerative colitis (UC), of whom 11 patients (25.5%) had a history of previous resection, and 1 patient (2.3%) was being followed for depression.
The surgical indications were GCA in 12 cases (27.9%), stenosis in 18 cases (41.8%), perforation in 1 case (2.3%), abscess in 8 cases (18.6%), and fistula in 4 cases (9.3%).
Our patients underwent ileo-caecal resection in 22 cases (51.2%), hemicolectomy in 6 patients (14%), coloproctectomy in 3 patients (7%), sub-total colectomy in 11 patients (25.6%), of whom 18 patients (41.9%) had an ostomy.
On the announcement of a possible surgical procedure, the thymic symptoms and feelings expressed by patients can be classified as follows: preoperative anxiety in 18 patients (41.9%), fear of death in 7 patients (16.3%), while 24 patients (55.8%) were indifferent.
The main anxiety-generating concern was postoperative pain in 7 patients (14%), potential complications in 7 patients (16.3%), failure of the procedure in 6 patients (14%), fear of dying in 7 patients (16.3%), and 25 patients (58.1%) expressed no anxiety.
The postoperative psychological experience was unremarkable in 37 patients (86%), 3 patients (7%) reported transient postoperative sadness and 3 patients (7%) developed postoperative depression, prompting consultation with a psychiatrist.

Conclusion

The impact of surgery in IBD patients not only concerns the body, but also has an effect on psychological well-being.
This study found that the pre-operative period induces a significant burden of anxiety in these patients, and depression in some.